Unanswered Questions About the COVID-19 Pandemic

Over 704 million people have been diagnosed with COVID-19 worldwide [1]. Some did not feel sick at all, but some became very ill. Patients had physical symptoms such as shortness of breath, chest pain, dizziness, racing heartbeat, headaches, low energy/tiredness, trouble sleeping, and back pain—which you can read about in this Frontiers for Young Minds article. In addition, many people who had COVID-19 also had worse mental health later, such as feeling worried, sad, or experiencing anxiety or depression [1]. Many people feel down when they are ill, but what makes COVID-19 unusual is that many people continue to feel anxious or sad long after they have recovered [2]. We were curious if family members and close friends (which we will now shorten to “relatives”) of COVID-19 patients were also affected. Do they also experience worse mental health?

How We Collected the Data

We used online surveys to answer our research questions. Surveys are a clearly designed set of questions used to collect data about a certain topic [3]. We collected information from four countries in Northern Europe: Iceland, Norway, Sweden, and the United Kingdom (Figure 1, top). More than 160,000 adults living in these countries filled in our surveys. Each person (called a participant) answered a set of questions about their lives, mental health (symptoms of anxiety and depression), and COVID-19 (if they or a family member or friend was sick with COVID-19 and how severe the illness was). In each country, participants answered similar questions in their native language [4].

Each group of researchers analyzed the data in the same way and sent the results to Sweden. The Swedish team combined the results to obtain the final result. We did this to keep every participant’s data safe in their own country, so no person could be recognized. Finally, we discussed the combined results and wrote down our findings together (the whole research process is illustrated in Figure 1, bottom).

Measuring Anxiety and Depression

There are many ways to measure anxiety and depression symptoms. We measured these symptoms the same way in each country, so we could easily compare results. We asked our participants to answer several questions about anxiety and depression. People who had symptoms beyond normal feelings of anxiety and sadness at the time of the survey were categorized as having “anxiety/depressive symptoms”. Those who were not feeling anxious or sad at all (or very little) were categorized as “not having anxiety/depressive symptoms”. After sorting everyone’s answers, we figured out what percentage of people had symptoms of anxiety or depression. We also took into account age, sex, and other important characteristics of the participants, which is important to avoid over- or underestimating the problem. Figuring out the percentage of people with mental health problems is relevant because those people might need help to feel better, like talking to a mental health expert.

What Did We Find?

We found that people who had a family member or friend diagnosed with COVID-19 were more likely to feel depressed and anxious than those whose loved ones did not have it. The interesting question is, how much more likely? This depended on how serious the illness was for the person with COVID-19 (Figure 2).

First, if the COVID-19 patient had no symptoms or only a mild infection and thus never had to go to the hospital to be treated, families and friends of COVID-19 patients in this group had a slightly higher prevalence of mental health symptoms (2%-3%) compared to those who did not have a loved one diagnosed with COVID-19. However, this difference was not clear and could have been due to chance. That is, the difference may appear only in the sample of people we happened to measure, and not among all the people we could have measured.

Second, if the relative was hospitalized due to COVID-19, their family members and friends had a larger risk of poor mental health—a 22% increased prevalence of experiencing depressive symptoms and 33% increased prevalence of anxiety symptoms. Based on this, could you explain what happens if the relative had life-threatening COVID-19 and was treated in the intensive care unit (ICU, a part of the hospital where extremely sick patients are cared for, pink diamonds), or if they died due to COVID-19 (blue diamonds)? You will find the solution in Figure 2 and the explanation in the next paragraph.

As you probably worked out, these two groups had an even higher risk of poor mental health! The largest increase in risk (57% higher risk of depressive symptoms and 58% higher risk of anxiety symptoms) was seen if the relative was admitted to the ICU.

You might be surprised that relatives of COVID-19 patients who died had a lower risk of experiencing these mental health symptoms. We were surprised, too. We can only speculate about the reasons. First, people who lost a family member or friend were still more likely to feel very sad or anxious compared to those who did not, or compared to those whose COVID-infected loved one did not go to the hospital. Second, fortunately, relatively few people in our study lost loved ones, which makes it tough to figure out exactly how many people were affected (This is why you see diamonds in the figure and not just dots: the wider diamonds represent that we are less certain about the exact risk, which is expressed as prevalence ratio). Moreover, because most COVID-19 patients died in the ICU, this group is part of the larger group of relatives who had a loved one admitted to the ICU. Third, and this is just a guess, but because many patients died in the ICU, perhaps relatives who lost a loved one received a lot of support from doctors, nurses, friends, and family, which could have helped them cope with their loss. Last, something called selection bias could have played a role. We could only collect information from people who volunteered for our study. Because people who feel very sad often find it difficult to take part in research studies, maybe people who lost a loved one found it too hard to participate after their loss.

How Long Did the Symptoms Last?

In Sweden, researchers collected data every month. This meant that in this country we could study how depressive and anxiety symptoms changed over time. In Figure 3, you can see three groups pictured:

• The first group had no family member or friend diagnosed with COVID-19. This is shown with a red line with a green band. For this group we chose a random starting point to make the study fair. In other words, we tried to reduce selection bias. Many people joined the study when they or a loved one fell ill due to COVID-19.

• The second group had family or friends with mild COVID-19 who did not need hospital care. So, the relative’s illness was mild. This is shown with a dark green line with a yellow band.

• The third group had family or friends who got very sick and had to go to the ICU. This is shown with a blue line with a pink band.

Higher numbers mean more people in that group felt very sad or anxious. In scientific terms, the prevalence was higher. For both depressive and anxiety symptoms, family and friends without COVID-19-infected loved ones or with loved ones who had a mild infection had symptoms that were stable over time. You can see this because the lines representing a group are more or less horizontal, with small changes. After the first month, when people might worry about the outcome of the infection the most, the lines are also close to each other. This means that, if the infected person was not very sick after the COVID-19 diagnosis, it did not result in worse mental health for their relatives. In contrast, the blue line is very different from the other two: it is always much higher. This means that family members and close friends of people who were very ill with COVID-19 experienced high levels of depressive and anxiety symptoms more often.

What Did We Learn?

Not only COVID-19 patients could experience signs of poor mental health when sick. Instead, family members and friends of COVID-19 patients can also feel sad or anxious after serious COVID-19 illness of a loved one. It is important to raise awareness and to make sure that the affected families get help. Although the COVID-19 pandemic is fortunately over, understanding how it affected people can help us to be more prepared to protect our mental health in the future.

Glossary

Anxiety: ↑ Feeling worried or scared. Anxiety can get in the way of doing things, like sleeping, playing with friends or going to school.

Depression: ↑ When people feel really sad, upset, or in a bad mood for a long time, which makes it hard for them to enjoy things they normally like doing.

Prevalence: ↑ How common a particular disease is in a specific population at a specific time. Prevalence is often expressed in percentages.

Prevalence Ratio: ↑ A measure used to compare prevalences between two groups, calculated by dividing the prevalences of two groups.

Selection Bias: ↑ sometimes the results of a study can be misleading because of how study participants were chosen. This often happens when volunteers are used in a study.

Conflict of Interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

AI Tool Statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

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